The aetiological relationship between congenital torticollis and obstetrical paralysis

Safety and effectiveness of integrative Korean medicine for the management of patients sustaining injuries in traffic accidents during pregnancy: A retrospective chart review and questionnaire survey

The number of traffic accidents (TAs) is rising each year, and the severity of injuries can vary. Many people experience limitations in activities of daily living following TAs, affecting their quality of life. In pregnant women, even simple injuries caused by a TA could lead to unfavorable obstetric outcomes. Thus, we conducted a retrospective chart review and follow-up questionnaire survey to assess the safety and effectiveness of integrative Korean medicine (KM) treatment for pregnant women injured in TAs. To assess integrative KM effectiveness, the numeric rating scale (NRS) for TA-related symptoms, neck disability index (NDI) score, Oswestry disability index (ODI) score, shoulder pain and disability index score, Western Ontario and McMaster Universities Arthritis Index score, EuroQol 5-dimension 5-level (EQ-5D-5L) score, and patient global impression of change score were investigated for pregnant women injured in TAs. Additionally, for safety evaluation, obstetric and neonatal outcomes, as well as symptoms related to pregnancy, were assessed. At the end of treatment and follow-up, there were significant reductions in NDI and ODI scores, as well as NRS for neck pain, lower back pain, and headache, compared to scores at baseline. EQ-5D-5L scores significantly increased. A follow-up of 50 patients showed no major differences in obstetric and neonatal outcomes compared to the typical outcomes that occur in pregnant women and neonates. Major improvements were observed in the symptoms of patients who underwent integrative KM treatment after being injured in TAs. The symptoms occurred at a rate similar to those in typical pregnant women, while causality with integrative KM treatment was assessed to be unlikely or unclear. Therefore, integrative KM treatment may be considered an alternative treatment option for pregnant women who currently have limited treatment options.

The outcomes of congenital torticollis delayed surgery in older children: A case series

INTRODUCTION AND IMPORTANCE

Congenital muscular torticollis is a benign affection defined as a contracture or fibrosis of the sternocleidomastoid muscle, causing ipsilateral inclination and contralateral rotation of the face and chin. The management is multidisciplinary, usually surgical and should start at very early age in infants to secure better results. Thus, the purpose of our study is to report the outcomes of delayed surgery performed in older children above 5 years old with late diagnosis.

CASE PRESENTATION

We report the cases of 4 patients aged between 5 and 11 years old and followed in our department for congenital torticollis. They were all born by vaginal delivery with vacuum extraction in two cases of breech presentation. Even if the condition is present at birth, most parents were not bothered by the cervical vicious neck position of their children until a later age, delaying the diagnosis. The clinical examination found a flexed head position on the right side in all cases, with contralateral rotation. Regarding the age, we proposed surgical treatment immediately for two of them, while two were sent to our department after multiple ineffective physiotherapy sessions. The surgery consisted on right distal tenotomy and a cervical collar was prescribed next to physiotherapy. They all had successful results with correction of head position and improvement of cervical range motion.

CLINICAL DISCUSSION

Children treated early with active and well monitored rehabilitation, recover completely and regain normal head position and mobility rapidly. In older children, above 5 years, they are more likely to develop sequels such as asymmetry of facial movement.

CONCLUSION

Delayed diagnosis after the age of 5 years old still can be managed successfully with a correction of the head position and rotation motion. However, in these older children, physiotherapy alone cannot be effective and should be associated to surgery. Moreover, once the diagnosis is done, surgical treatment should be performed to avoid wasting more time.

External treatment of herbal medicine with tuina in congenital muscular torticollis: A protocol for systematic review and meta-analysis

BACKGROUND

This study is the protocol to evaluate the clinical evidence for external treatments using herbal medicine (ETHM) with tuina as a congenital muscular treatment (CMT) in pediatrics.

METHODS

Eleven databases will be searched until June 2022, without any language restrictions: four English databases (MEDLINE, Pubmed, EMBASE, and The Cochrane Central Register of Database of Controlled Trials), three Chinese databases (China National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database), and four Korean electronic databases (Oriental Medicine Advanced Searching Integrated System, Korean Studies Information Service System, National Digital Science Links, and Research Information Sharing Service). This review will include randomized clinical trials (RCTs) of ETHM with tuina as an intervention versus the same tuina. All published RCTs for any ETHM for CMT will be included. Non-RCTs, RCT protocol, animal studies, case reports, reviews, and surveys will be excluded. The methodological quality assessment will be performed using the Cochrane risk of bias (ROBs). Review Manager version 5.4. will be used for the data synthesis and quantitative analysis.

RESULTS AND DISCUSSIONS

The systematic review and meta-analysis will provide evidence for ETHM as a treatment of CMT. The evidence can help clinicians and patients recognize more effective therapeutic and safe inventions.

INPLASY REGISTRATION NUMBER

INPLASY202210017.

Clinical features and management of the developmental dysplasia of the hip in congenital muscular torticollis

PURPOSE

A consistent relationship between CMT and DDH has been established. However, whether the presence of CMT has effect on clinical outcomes of DDH remains unanswered. This study aimed to evaluate clinical features and management of DDH in patients with CMT.

METHODS

We reviewed the medical records of 54 patients (91 hips) simultaneously diagnosed with DDH and CMT and included 54 patients (97 hips) with only DDH by random number method as the control group. Clinical and examination outcomes were recorded and compared, respectively.

RESULTS

The mean follow-up was 18.1 ± 14.5 months (range, 2 to 72 mo). In the DDH and CMT group, the age of initial treatment was lower (100.8 ± 92.3 vs. 229.0 ± 157.4 d, P < 0.001), and the rate of male significantly increased (42.6% vs. 11.1%, P < 0.001). Before treatment, development degree of hip was better than that of the DDH group. Therefore, patients with CMT had approximately 14 times greater odds of conservative treatment success than children in the DDH group (OR, 13.84; 95% CI, 3.16 to 60.60).

CONCLUSION

We concluded that CMT was not the risk factor for the failure of treatment. On the contrary, the identification of CMT may be beneficial to early discovery and treatment of DDH when we remain vigilant to perform physical exam and screen imaging of DDH for patients with CMT.

Congenital muscular torticollis - a proposal for treatment and physiotherapy

Congenital muscular torticollis (CMT) is a condition manifested by unilateral thickening and/or shortening of the sternocleidomastoid muscle. It can lead to local or global consequences (i.e., forced position and limitation of mobility of the cervical spine and head, delay of motor development). Early recognition of CMT symptoms and the implementation of conservative treatment, considered effective in the majority of cases, are an important part of physical therapy in CMT. The aim of the study is to review literature presenting the methods of physical therapy in CMT and to create the authors’ own proposals for treatment, based on the results of this review. Based on subject-matter literature and our own experience, algorithms for the rehabilitation procedure have been proposed, presenting the general scheme of action in CMT and management depending on the clinical form and age of the child in whom therapy was started (up to 5 months and after 6 months). The authors’ proposed algorithm did not strictly specify the frequency of sessions with a physiotherapist, because this is the resultant of many factors. The main ones include the child's age on the day of initiation of therapy, the clinical form of torticollis, the presence of muscle tone disorders and/or skull asymmetry, but also, the correctness of performing exercises proposed as part of the home-based programme, regularity of therapy and compliance with postural programme principles.

Relationship between sonography of sternocleidomastoid muscle and cervical passive range of motion in infants with congenital muscular torticollis

Background

An abnormal sternocleidomastoid muscle in congenital muscular torticollis can be classified into one of the four types via sonography. However, this categorization lacks quantitative measurements. The purpose of the study was to determine quantitative measurements of the sonograms via image analysis.

Methods

Infants younger than 12 months of age suspected of having congenital muscular torticollis were included. Intraclass correlation coefficient estimates for interobserver reliability and a simple regression analysis for criterion validity were calculated. Spearman correlation analysis was then performed. The analyzed parameters included cervical passive range of motion for lateral flexion and rotation, area, brightness, max/min Feret's diameters, and muscular width/thickness.

Results

Of the 29 (4.0 ± 2.6 months) screened infants, 13 (1.9 ± 1.7 months) were included. Nine were male, and 4 were female. Seven infants with mass were ultrasonographically classified into type I, and the other six infants were classified into type II. The affected/unaffected side ratios of cervical passive range of motion for lateral flexion and rotation were 0.92 ± 0.13 and 0.88 ± 0.16, respectively. The parameters measured on the sonograms were reliable, and the max/min Feret's diameters were valid measurements. The affected/unaffected side ratio of cervical passive range of motion for rotation significantly correlated with the affected/unaffected side ratios of the sternocleidomastoid muscle sonogram on area (r = −0.62, p = 0.03) and min Feret's diameter (r = −0.69, p = 0.01).

Conclusions

The area and min Feret's diameter were efficacious parameters for image analysis on sternocleidomastoid sonograms, and the min Feret's diameter would be more suitable than thickness for measuring the thickening SCM in transverse view. A healthy control group, more data and follow-up would be needed to confirm the changes on the SCM sonograms for clinical decision.

Do obstetric risk factors truly influence the etiopathogenesis of congenital muscular torticollis?

Background

Congenital muscular torticollis (CMT) is seen in childhood and presents within months after birth. The etiology remains unknown; however, medical textbooks suggest trauma at birth as a main reason. The aim of this study was to systematically describe obstetric and perinatal outcomes in a population of children with a confirmed congenital muscular torticollis diagnosis.

Materials and methods

Children with a validated diagnosis of congenital muscular torticollis born at Aarhus University Hospital from 2000 to 2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristics were obtained from databases and from medical records, and systematically described.

Results

In this study, there were no differences in birth characteristics in children with left- and right-sided torticollis, between boys and girls or between the conservatively treated and the children who needed surgery. Most of the children with congenital muscular torticollis in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.

Conclusions

The results of the present study suggests that complicated birth or birth trauma may not be the main cause of congenital muscular torticollis and point towards intrauterine and prenatal reasons for its development.

Level of evidence according to OCEBM levels of evidence working group

3

Quantitative analysis of magnetic resonance imaging of the neck and its usefulness in management of congenital muscular torticollis

Objective

To quantify magnetic resonance imaging (MRI) findings of congenital muscular torticollis (CMT) and to demonstrate the usefulness of quantitative MRI findings in the management of CMT.

Methods

This was a retrospective study of 160 subjects with CMT who had undergone neck MRI at the age of 48 months or younger at a tertiary medical center. Among the 160 subjects, 54 had undergone surgical release of CMT and 106 subjects had not undergone surgery. For the quantitative analysis, the ratios of area and intensity of the MRI findings were measured and compared between the two groups (ratio of area = the largest cross-sectional area of the SCM with CMT - the cross-sectional area of the contralateral SCM without CMT / the cross-sectional area of the contralateral SCM without CMT; ratio of intensity = the mean gray color intensity of the contralateral SCM without CMT - the lowest mean gray color intensity of the SCM with CMT / the mean gray color intensity of the contralateral SCM without CMT). Receiver operating characteristic (ROC) curve analysis was conducted for the ratios of area and intensity in order to find the optimal cutoff value for determining the need for surgery in CMT cases.

Results

The ratios of area and intensity were significantly higher in the surgical group than in the non-surgical group (p≤0.001), suggesting that the sternocleidomastoid muscle (SCM) was thicker and darker in the surgical group than in the non-surgical group. The optimal cutoff value for the ratio of area was 0.17 and that for the ratio of intensity was 0.05. All subjects with a ratio of intensity less than 0.03 belonged to the non-surgical group, and all subjects with a ratio of intensity greater than 0.16 were categorized in the surgical group.

Conclusion

The quantitative MRI findings, i.e., ratios of area and intensity, may provide a guideline for deciding the need for surgical intervention in CMT patients. Further prospective studies are required to verify these findings.

Factors that affect the rehabilitation duration in patients with congenital muscular torticollis

OBJECTIVE

To determine which factors affect the rehabilitation duration in patients with congenital muscular torticollis (CMT) and to predict the duration of rehabilitation and prognosis.

METHODS

One hundred and eighteen patients (79 males and 39 females) who were diagnosed with CMT and received physical therapy were enrolled in this study. We retrospectively reviewed the information in terms of sex, gestational age, birth weight, methods of delivery, fetal presentation, age at diagnosis, the affected sternocleidomastoid (SCM) muscle site, SCM muscle thickness, ratio of muscle thickness on the affected side to that on the unaffected side (called the 'abnormal/normal [A/N] ratio'), and range of motion for cervical rotation and side bending.

RESULTS

The SCM muscle thickness and A/N ratio had a positive linear relationship with the rehabilitation duration. Patients who were in the breech position needed longer rehabilitation. The birth weight and age at diagnosis were negatively correlated with the rehabilitation duration. However, the cervical range of motion, mass site, sex, gestational age, and methods of delivery were not correlated with the rehabilitation duration.

CONCLUSION

Patients with a thicker SCM, lower birth weight, and history of breech delivery had a longer rehabilitation duration.

Integrative analysis of congenital muscular torticollis: from gene expression to clinical significance

Background

Congenital muscular torticollis (CMT) is characterized by thickening and/or tightness of the unilateral sternocleidomastoid muscle (SCM), ending up with torticollis. Our aim was to identify differentially expressed genes (DEGs) and novel protein interaction network modules of CMT, and to discover the relationship between gene expressions and clinical severity of CMT.

Results

Twenty-eight sternocleidomastoid muscles (SCMs) from 23 subjects with CMT and 5 SCMs without CMT were allocated for microarray, MRI, or imunohistochemical studies. We first identified 269 genes as the DEGs in CMT. Gene ontology enrichment analysis revealed that the main function of the DEGs is for extracellular region part during developmental processes. Five CMT-related protein network modules were identified, which showed that the important pathway is fibrosis related with collagen and elastin fibrillogenesis with an evidence of DNA repair mechanism. Interestingly, the expression levels of the 8 DEGs called CMT signature genes whose mRNA expression was double-confirmed by quantitative real time PCR showed good correlation with the severity of CMT which was measured with the pre-operational MRI images (R² ranging from 0.82 to 0.21). Moreover, the protein expressions of ELN, ASPN and CHD3 which were identified from the CMT-related protein network modules demonstrated the differential expression between the CMT and normal SCM.

Conclusions

We here provided an integrative analysis of CMT from gene expression to clinical significance, which showed good correlation with clinical severity of CMT. Furthermore, the CMT-related protein network modules were identified, which provided more in-depth understanding of pathophysiology of CMT.

Comparison of clinical severity of congenital muscular torticollis based on the method of child birth

OBJECTIVE

To compare the clinical severity of congenital muscular torticollis (CMT) based on the method of child birth.

METHOD

Children diagnosed with CMT and who were < 6-years-of-age at the time of their first visit at the Center for Torticollis, Ajou Medical Center, were included in this study. The medical records were retrospectively reviewed with reference to the method of child birth and the clinical severity of CMT. The clinical severity of CMT was determined either by whether stretching exercises were needed for the children <6-month-of-age or whether surgical release was required for the children ≥6-months-of-age at the time of the first visit.

RESULTS

One hundred seventy eight subjects with CMT were enrolled. There was no significant difference in the rate of surgical release according to the method of child birth. For 132 patients <6-month-of-age there was also no significant difference in the rate of stretching exercises.

CONCLUSION

There was no significant difference in the clinical severity of CMT based on the method of child birth. This finding suggests that prenatal factors alone could be a cause of CMT and that the clinical severity of CMT in children delivered by Cesarean section is not different when compared with the severity of CMT in children born through vaginal delivery.

Screening for the coexistence of congenital muscular torticollis and developmental dysplasia of hip

Objective

To investigate the coexistence rate and related factors of developmental dysplasia of the hip (DDH) and congenital muscular torticollis (CMT), and to determine whether ultrasonography (US) gives good value for screening of DDH in CMT.

Method

We prospectively examined 121 infants (73 males and 48 females) diagnosed with CMT to determine the incidence of DDH by US. We also assessed the relationship between neck US findings and DDH occurrence, and investigated the clinical features of CMT related to DDH.

Results

18 patients (14.9%) were diagnosed as having DDH by US. However, most DDH was subclinical and spontaneously resolved. Only 2 patients (1.7%) needed to be treated with a harness. The positive predictive value of clinical examinations for DDH was 52.6% and patients treated by harness were all clinically positive. DDH was more common in the left side (13 left, 4 right, 1 both), but 6 out of 18 DDH (33.3%) cases presented on the contralateral side of CMT. Sex difference was not observed. Breech presentation and oligohydramnios were not related to DDH occurrence. Neck US findings did not correlate with DDH occurrence.

Conclusion

The coexistence rate of CMT and DDH was concluded to be 14.9%. If only DDH cases that required treatment were included, the coexistence rate of these two disorders would be lowered to 1.7%. All of these patients showed positive findings in clinical examination. Therefore, hip US should not be recommended routinely for patients with CMT.

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.

The thickness of the sternocleidomastoid muscle as a prognostic factor for congenital muscular torticollis

Objective

To examine whether the thickness of the sternocleidomastoid muscle (SCM) could be used as a prognostic factor for congenital muscular torticollis (CMT).

Method

This was a retrospective study conducted in a pediatric rehabilitation service at a tertiary medical center. Fifty-two children who met the following inclusion criteria were included: 1) children who were 3 month-old or younger, 2) children diagnosed with CMT, 3) passive rotation of the face toward the shoulder of the tilted side ≤60°, 4) children who had been managed according to the clinical pathway for CMT, 5) children who had been followed up for 6 months or more after the end of treatment. The duration and total number of stretching exercise sessions were reviewed with reference to the thickness of the SCM.

Results

Among the 52 children with CMT, 46 children were successfully managed with only stretching exercise of the SCM for 1-6 weeks (group 1: 88.5%) and 6 children were managed with botulinum toxin A injection, surgical release or both in addition to stretching exercise (group 2: 11.5%). The difference in the SCM thickness between the affected and normal sides was significantly greater in group 2 than that in group 1 (p=0.026). A strong correlation was found between the total duration of stretching exercise and the difference in the SCM thickness in group 1 (Pearson' γ=0.429; p=0.003).

Conclusion

Children with a thicker SCM seem to require a longer duration of stretching exercise and other therapeutic interventions in addition to stretching exercise for CMT. Therefore, the thickness of the SCM may be one prognostic factor for CMT treatment.

The relationship between developmental dysplasia of the hip and congenital muscular torticollis

Multiple studies report a correlation between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) at a rate between 2% and 29%. Most of these studies were completed before the routine use of hip ultrasound. This study assesses the incidence of DDH in a referral population with CMT and the incidence of CMT in a referral population with DDH. We retrospectively reviewed 186 patients referred with a primary diagnosis of DDH and 109 patients referred with a primary diagnosis of CMT between 1995 and 2004. All patients were screened for DDH with ultrasound if they were younger than 4 months and plain radiographs in older children. Among the patients with a primary diagnosis of DDH, 5.9% were subsequently diagnosed with CMT. However, infants who were less than 1 month old when diagnosed with DDH had a 9% risk of subsequent development of CMT. Among the patients primarily diagnosed with CMT, 3.7% were subsequently diagnosed with DDH. Among the patients with DDH, there was a 7.9% coexistence of CMT, regardless of which was diagnosed first, and among the patients with CMT, there was a 12.5% coexistence of DDH. Boys with DDH were 4.97 times more likely than girls to have both DDH and CMT regardless of which diagnosis preceded the other. Our results confirm that patients with CMT should be screened for DDH, and infants, especially boys, treated for DDH should be followed for the development of CMT.

Predictive Model for Congenital Muscular Torticollis: Analysis of 1021 Infants With Sonography

OBJECTIVE

To construct a predictive model to foretell congenital muscular torticollis (CMT) on the basis of clinical correlates.

DESIGN

Correlation study.

SETTING

Regional hospital.

PARTICIPANTS

A consecutive series of 1021 newborn infants.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Participants underwent portable ultrasonography to diagnose CMT. Significant clinical correlates were identified to construct a predictive model using the logistic regression model.

RESULTS

Forty of 1021 infants were diagnosed with CMT using ultrasonography, yielding an overall incidence of 3.92%. Birth body length (odds ratio [OR]=1.38; 95% confidence interval [CI], 1.49-2.38), facial asymmetry (OR=21.75; 95% CI, 6.6-71.7), plagiocephaly (OR=22.3; 95% CI, 7.01-70.95), perineal trauma during delivery (OR=4.26; 95% CI, 1.25-14.52), and primiparity (OR=6.32; 95% CI, 2.34-17.04) were significant correlates. A predictive logistic regression model with the incorporation of these 4 correlates was developed. We used cross-validation with a receiver operating characteristic curve to validate the predictive model.

CONCLUSIONS

Our study successfully developed a quantitative predictive model for estimating the risk of CMT on the basis of clinical correlates only. This model has good discriminative ability for classifying CMT and non-CMT by yielding acceptable values of false-negative and false-positive cases.

Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases

BACKGROUND

The natural history of congenital muscular torticollis and the outcome of different treatment modalities have been poorly investigated, and the results of treatment have varied considerably.

METHODS

The main objective of this prospective study was to evaluate the outcomes of 821 consecutive patients with congenital muscular torticollis who were first seen when they were less than one year old, were treated with a standardized program of manual stretching, and were followed for a mean of 4.5 years. Before treatment, the patients were classified into one of three clinical groups: (1) palpable sternomastoid tumor, (2) muscular torticollis (thickening and tightness of the sternocleidomastoid muscle), and (3) postural torticollis (torticollis but no tightness or tumor).

RESULTS

Of the 821 patients, 452 (55%) had a sternomastoid tumor; 276 (34%), muscular torticollis; and ninety-three (11%), postural torticollis. Multivariate analysis of the outcomes showed that (1) the duration of treatment was significantly associated with the clinical group (p < 0.0001), a passive rotation deficit of the neck (p < 0.0001), involvement of the right side (p < 0.0001), difficulties with the birth (p < 0.009), and age at presentation (p < 0.0001); (2) the overall final assessment score was associated with the rotation deficit (p = 0.02), age at presentation (p = 0.014), and duration of treatment (p < 0.0001); and (3) subsequent surgical treatment was required by 8% (thirty-four) of the 452 patients in the sternomastoid tumor group compared with 3% (eight) of the 276 patients in the muscular torticollis group and 0% (none) of the ninety-three patients in the postural torticollis group.

CONCLUSIONS

This large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before the age of one year. The most important factors that predict the outcome of manual stretching are the clinical group, the initial deficit in rotation of the neck, and the age of the patient at presentation. Surgical treatment is indicated when a patient has undergone at least six months of controlled manual stretching and has residual head tilt, deficits of passive rotation and lateral bending of the neck of >15 degrees, a tight muscular band or tumor, and a poor outcome according to our special assessment chart.

Snapping during manual stretching in congenital muscular torticollis

Manual stretching frequently is used in the treatment of congenital muscular torticollis in infants. During manipulation, it is not uncommon for the sternocleidomastoid muscle to snap or suddenly give way. The main objective of this study was to evaluate the predisposing causes and clinical significance of such snapping. Four hundred fifty-five patients younger than 1 year of age with congenital muscular torticollis treated with a standardized gentle manual stretching program during a 13-year period were studied. Using prospective standardized assessment parameters, the pretreatment, treatment, and followup results of a group of 41 patients with snapping detected during treatment were compared with the results of a group of 404 patients without snapping during treatment. The group with snapping was associated with a more severe sternomastoid tumor, higher incidence of hip dysplasia, earlier clinical presentation, and shorter duration of treatment. With a mean followup of 3.5 years, the group with snapping was not different from the group that had no snapping in the final assessment score and percentage requiring surgery. From this study, unintentional snapping during the gentle manipulation treatment of congenital muscular torticollis has clinical and ultrasonographic evidence of partial or complete rupture of the sternocleidomastoid muscle. No long-term deleterious effect on the outcome was observed after the snapping.

Correlation of ultrasonographic imaging of congenital muscular torticollis with clinical assessment in infants

Congenital muscular torticollis (CMT) is a common problem affecting infants and children. There is a general lack of standard clinical classification or objective assessment methods. Ultrasonographic imaging of the sternomastoid muscle (SCM) has been carried out in a consecutive series of 436 infants less than 1 y old presenting with CMT over a 5-y period. All patients were classified into three clinical groups: postural torticollis, muscular torticollis and sternomastoid tumor. The severity of the torticollis was also expressed into four subgroups according to the degree of deficits in passive rotation of the neck. The ultrasonographic image of the affected SCM included the echogenicity, texture, motility, softness and the transverse and longitudinal extent of the involvement. The disturbance in the quantitative measurement of the transverse diameter of the lower and upper third of the SCM and the ratio of the measurement to the normal side was recorded. The qualitative and quantitative changes in the SCM image were found to correlate significantly with the clinical typing and severity of rotational deficits of the neck. Ultrasonographic imaging has important potential clinical application in helping the diagnosis, prognostication and monitoring of progress of CMT longitudinally.

The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases

BACKGROUND/PURPOSE

The main objectives of this study were to define the clinical patterns and characteristics of congenital muscular torticollis (CMT) presented in the first year of life and to study the outcome of different treatment methods.

METHODS

This is a prospective study of all CMT patients seen in 1 center over a 12-year period with uniform recording system, assessment methods, and treatment protocol.

RESULTS

From a total of 1,086 CMT infants, 3 clinical subgroups of sternomastoid tumor (SMT; 42.7%), muscular torticollis (MT; 30.6%), and postural torticollis (POST; 22.1%) were identified. The SMT group was found to present earlier within the first 3 months and was associated with higher incidence of breech presentation (19.5%), difficult labor (56%), and hip dysplasia (6.81%). Severity of limitation of passive neck rotation range (ROTGp) was found to correlate significantly with the presence of SMT, bigger tumor size, hip dysplasia, degree of head tilt, and craniofacial asymmetry.

CONCLUSIONS

A total of 24.5% of the patients with initial deficits of passive rotation of less than 10 degrees showed excellent and good outcome with active home positioning and stimulation program. The remaining cases with rotation deficits of over 10 degrees and treated with manual stretching program showed an overall excellent to good results in 91.1% with 5.1% requiring subsequent surgical treatment. The most important prognostic factors for the necessity of surgical treatment were the clinical subgroup, the ROTGp, and the age at presentation (P < .001).

Diagnosis of fibromatosis colli by fine needle aspiration (FNA) cytology

This study presents eight cases of fibromatosis colli accurately diagnosed by FNA cytology. Fibromatosis colli is a rare fibroblastic lesion that manifests in the sternocleidomastoid muscle during the first to second months after birth. The tumours varied in size from 1 to 3 cm and engaged the lower, middle as well as the upper part of the sternocleidomastoid muscle. The FNA cytology smears showed mostly mature fibroblasts in a background of pink granular material and fragments of striated muscle fibres with degeneration. The cytological presentation together with the typical clinical setting will allow a definitive and accurate diagnosis, avoiding surgery.

Congenital muscular torticollis: is heredity a possible factor in a family with five torticollis patients in three generations?

Although the clinical features of congenital muscular torticollis are well known, the cause of this disorder still remains hypothetical. The role of heredity is not well established, because there have been only a few studies on it. We presented a family in which five members suffer from CMT in three generations, two of whom were operated on. According to the pattern in the pedigree, probably an autosomal dominant condition could be considered.

The prevalence of nonmuscular causes of torticollis in children

Torticollis in children may result from a wide variety of pathologic processes. We retrospectively analyzed 288 patients seen in a tertiary care pediatric orthopedic facility for the evaluation of torticollis over a 10-year period to ascertain the frequency of nonmuscular causes of this condition. Fifty-three of these children (18.4% of the study population) had a nonmuscular etiology for their torticollis. Of these 53 patients, Klippel-Feil anomalies were present in 16 (30%), and an underlying neurologic disorder was present in 27 (51%). These neurologic conditions included ocular disorders in 12 (23%) patients, brachial plexus palsies in nine (17%) patients, and lesions involving the central nervous system in six (11%) patients. We conclude that nonmuscular causes of torticollis are collectively not rare. In a child without an identifiable muscular etiology for torticollis, Klippel-Feil anomalies or an underlying neurologic disorder is likely to be the cause of the deformity in the majority of patients.